PLEASE ANSWER ALL QUESTIONS BY CHECKING YES OR NO.
All responses are kept confidential.
6. Do you have or have you ever had:
C. Cardiovascular disease (heart attack, heart murmur, coronary artery
disease, angina, high blood pressure, stroke, palpitations, heart surgery,
D. Lung disease (asthma, emphysema, chronic cough, pneumonia, tuberculosis,
shortness of breath, chest pain, severe coughing)?
E. Neurologic-psychiatric disorders (convulsions, epilepsy, seizures,
fainting, psychiatric treatment, dizziness, nervous disorder or breakdown)?
7. Are you using or taking any of the following:
8. Are you allergic or had bad reaction to:
I understand the importance of a truthful health history to assist the
doctor in providing the best care possible. I have had the opportunity
to discuss my health history with my doctor.